Abstracts

Rationale: Objective: To report a case of a patient with a refractory temporal lobe epilepsy, who underwent a Wada test for speech and memory lateralization as part of a pre-operative evaluation for left temporal lobectomy. He suffered an ischemic stroke after Wada procedure and received intravenous Alteplase, a tissue plasminogen activator (t-PA), which resolved his stroke symptoms. Three months later, he had a successful left temporal lobectomy and remains seizure free since the surgery. Methods: Background: The Wada test, also known as the "intracarotid sodium amobarbital procedure" (ISAP) has become a standard procedure in neuropsychological evaluation for surgical treatment of temporal lobe epilepsy. The Wada test named after neurologist Juhn Wada, is used to establish cerebral language and memory representation of each hemisphere. ISAP associated with cerebral angiography is generally safe with a small risk of complications including encephalopathy, seizures, carotid artery dissections, hemorrhage at the catheter insertion site and infection; the risk of stroke is less than 1 percent. One accidental death during ISAP associated with cerebral angiography was reported in the literature. Results: Case Description: A 50 year old male with intractable epilepsy since age 10 secondary to spinal meningitis had video EEG monitoring that captured seizures emanating from the left temporal region and imaging that showed left mesial temporal sclerosis. He was thought to be a good candidate for left temporal lobectomy. A Wada test was performed successfully and showed speech and memory localized in the right hemisphere. In the recovery room, one hour after the ISAP, he developed acute right face, arm and leg weakness. His NIH stroke scale was 6. His brain MRI identified an acute ischemic infarct in the left corona radiate with negative findings in the MRI angiography of head and neck. Intravenous t-PA was given within 2 hours from the last known normal time. The patient was admitted to the neurology intensive care unit. His stroke symptoms resolved 5 hours after t-PA administration with NIH stroke scale of 0. His stroke work up did not reveal any risk factors for embolic stroke. He recovered well from his stroke and did not have any residual weakness. Three months later, he underwent a left anterior temporal lobectomy and mesial hippocampectomy without any complication. He remains seizure free for the last 3 years since the lobectomy. Conclusions: Conclusions: A Wada test is an overall low risk procedure. Complication of embolic stroke is a rare incident, secondary to vessel spasm after ISAP associated with cerebral angiography. We have performed several hundred Wada tests; this is the only patient to have complication of stroke. Since the patient remained in the post operation recovery room for few hours after ISAP, any signs and symptoms of stroke could be identified quickly and Intravenous t-PA could be administered within the window. The patient had good outcome with complete resolution of stroke and remains seizure free after temporal lobectomy.